Primary Care Interventions for Early Childhood Development: A ... · Interventions used a variety of theory-based behavior change strategies such as modeling, group discussion, role

aInstitute for Healthcare Delivery and Population Science, Baystate Health, Springfield, Massachusetts; bDepartment of Pediatrics, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts; cSchool of Medicine, Boston University, Boston, Massachusetts; and dDivision of General Pediatrics, Boston Medical Center, Boston, Massachusetts

Dr Peacock-Chambers conceptualized and designed the study, participated in study selection, conducted the analyses, drafted the initial manuscript, and revised the manuscript; Ms Ivy participated in the study selection, data collection, and analyses, drafted sections of the initial manuscript, and reviewed and revised the manuscript; Dr Bair-Merritt conceptualized and designed the study and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

DOI: https:// doi. org/ 10. 1542/ peds. 2017- 1661

To cite: Peacock-Chambers E, Ivy K, Bair-Merritt M. Primary Care Interventions for Early Childhood Development: A Systematic Review. Pediatrics. 2017;140(6):e20171661

CONTEXT: The pediatric primary care setting offers a platform to promote positive parenting behaviors and the optimal development of young children. Many new interventions have been developed and tested in this setting over the past 2 decades.OBJECTIVE: To summarize the recent published evidence regarding the impact of primary care–based interventions on parenting behaviors and child development outcomes; to provide recommendations for incorporation of effective interventions into pediatric clinics.DATA SOURCES: A literature search of PubMed and PsycINFO was conducted from January 1, 1999, to February 14, 2017.STUDY SELECTION: Publications in which primary care–based interventions and reported outcomes regarding the child’s development or parenting behaviors associated with the promotion of optimal child development are described.DATA EXTRACTION: Forty-eight studies in which 24 interventions were described were included. Levels of evidence and specific outcome measures are reported.RESULTS: Included interventions were categorized as general developmental support, general behavioral development, or topic-specific interventions. Two interventions resulted in reductions in developmental delay, 4 improved cognitive development scores, and 6 resulted in improved behavioral intensity or reduction in behavioral problems. Interventions used a variety of theory-based behavior change strategies such as modeling, group discussion, role play, homework assignment, coaching, and video-recorded interactions. Three interventions report the cost of the intervention.LIMITATIONS: Community or home-based interventions were excluded.CONCLUSIONS: Although several interventions resulted in improved child development outcomes for children aged 0 to 3 years, comparison across studies and interventions is limited by use of different outcome measures, time of evaluation, and variability of results.

Primary Care Interventions for Early Childhood Development: A Systematic ReviewElizabeth Peacock-Chambers, MD, MSc, a, b Kathryn Ivy, BA, c Megan Bair-Merritt, MD, MSCEd

abstract

Peacock-Chambers et alPrimary Care Interventions for Early Childhood Development: A Systematic Review

2017

https://doi.org/10.1542/peds.2017-1661

6PediatricsROUGH GALLEY PROOF

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The first 3 years of life are a critical period for child brain growth and development, with the potential to impact later social, economic, and health-related quality of life.1 Pediatric primary care, which includes health supervision and anticipatory guidance, offers an important entry point for the promotion of optimal child development in the United States because it is a universal service with frequent encounters in the first 3 years of a child’s life.2, 3 In a systematic review by Regalado and Halfon4 of publications between 1979 and 1999, the authors summarized developmental assessments, anticipatory guidance, and specific interventions used to promote development of children aged 0 to 3 years in primary care settings. They comment on the efficacy of anticipatory guidance and problem-focused counseling interventions as well as the challenges and barriers to implementing such interventions in practice. Importantly, the authors found that targeted skill-building interventions that were focused on improving parent-child interaction, 5 or specific parenting behaviors (such as book sharing, 6 coping with infant colic, 7 sleep training, 8 or non-harsh discipline9) proved to be the most effective.

New interventions to promote the optimal development of young children continue to be developed and tested. Additionally, in 2012, the American Academy of Pediatrics called for the pediatric community to “catalyze fundamental change in early childhood policy and services.” 3 This declaration underscored the need for new, more effective strategies to increase the impact of primary care on promoting optimal development for young children in the United States. Taking this statement along with the rapidly changing landscape of US pediatric primary care systems, including the rise of the medical home model10

and new models of well-child care delivery, 11 a comprehensive and current review of these interventions is needed. The authors of such a review must summarize the impact these interventions have on child development outcomes, building on a previous review focused on positive parenting outcomes.12 Furthermore, scientists and clinicians could benefit from a synthesis of available evidence-based interventions to inform areas still in need of future study. Therefore, our objective in this systematic review was to examine the interventions implemented in connection with primary care to promote optimal child development for children aged 0 to 3 years from 1999 to 2017 and to summarize the efficacy of these interventions on child and parent level outcomes.

MeThODs

search strategy

This systematic review was conducted by following the PRISMA guidelines13 to identify interventions delivered in connection with primary care setting for the promotion of optimal early development of children aged 0 to 3 years. For the purpose of this review, pediatric primary care or pediatric clinics were defined as family medicine, pediatric, or public health clinics (outside of the United States) providing preventive care to children. Interventions were defined as education, counseling, or other provider-parent engagement beyond screening for developmental delay. Parents could include nonbiological parents, grandparents, or caregivers, but henceforth we refer to these caregivers as parents. Our inclusion criteria required that English, peer-reviewed publications: (1) examined interventions for the promotion of optimal child development for children aged 0 to 3 years, (2) described delivery of the intervention within or associated with a primary care setting, and

(3) reported outcomes regarding the child’s development (cognitive, behavior, or social-emotional) or parenting behaviors associated with the promotion of optimal child development (eg, book sharing, positive discipline, or parental sensitivity using validated measures). We excluded review articles and articles that targeted children with developmental diagnoses (eg, autism, attention-deficit/hyperactivity disorder, oppositional defiant disorder) or extreme prematurity (<28 weeks’ gestation). We also excluded studies solely of parents with known substance abuse or depression because these mental health illnesses frequently require additional targeted treatment. We excluded studies that only reported outcomes regarding child sleep. Publications were considered from any country if they met the above listed criteria.

PubMed and PsycINFO were searched by E.P-C. for a selection of articles published from January 1, 1999, through February 14, 2017, using these key words: (“child development” OR “parenting”) AND (“pediatrics” OR “primary care”). In addition, we searched references of included articles and related review articles. The final list of included articles was reviewed with 2 expert child development consultants not affiliated with the study: 1 developmental behavioral pediatrician with more than 30 years of clinical and intervention development experience and a second developmental behavioral pediatrician that has written extensively about child developmental assessments and promotion in clinical settings.

study selection

Initial search terms were intentionally broad; therefore, 1 investigator (E.P-C.) screened the initial list of titles to exclude clearly irrelevant studies. Two investigators

PEACoCK-ChAMBERS et al2


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independently screened abstracts of all potentially relevant titles (E.P-C. and K.I.) using inclusion and exclusion criteria listed above to identify studies for full text review. The investigators resolved disagreements by consensus, reviewing full-text articles and involving a third investigator as needed.

Data Abstraction and Levels of evidence

Data were abstracted from full-text articles by K.I. by using a structured form that included information on intervention delivery (content, frequency, duration, person implementing, location, specific developmental focus, and cost), study design, child age, sample size, study population, outcome measures (child or parent outcomes), and findings. Abstracted data were verified and checked for consistency by a separate abstractor (E.P-C.). Two reviewers (E.P-C. and K.I.) independently assessed the levels of evidence of the studies using a clinically relevant quality rating scheme modified from the Oxford Centre for Evidence-Based Medicine Levels of Evidence.14 Levels of evidence are classified as follows: level 1, properly powered and conducted randomized clinical trials; level 2, well-designed controlled trial without randomization, prospective comparative cohort trial; level 3, case-control studies, retrospective cohort studies; level 4, case series with or without intervention, cross-sectional study. Disagreements regarding level of evidence scores were resolved through discussion and consensus.

ResuLTs

Description of study selection

Initial searches yielded 7605 titles from all search engines. Of these, 528 abstracts (411 from PubMed and 117 from PsychInfo) were retained, with an additional 40 abstracts

identified from reference lists. After the removal of 55 duplicate articles, 513 abstracts were reviewed for inclusion and/or exclusion criteria (Fig 1). Four-hundred and twenty-five articles were excluded during abstract review, resulting in the full-text review of 88 articles. Forty articles were excluded on full-text review, yielding 48 articles in which 24 interventions were described that met all inclusion and exclusion criteria.

Intervention Description

Interventions were conducted in 12 different countries: United States, Australia, China, Holland, Canada, Norway, Turkey, Chile, Jamaica, Antigua, St. Lucia, and Iran. Interventions identified in this review could be grouped in 3 broad categories on the basis of the described intervention “focus” as

summarized in Tables 1 through 3: (1) general developmental support, such as language, social, gross and fine motor development (9 interventions, 20 studies); (2) general behavioral development, such as managing negative child behaviors through developing positive disciplinary strategies (8 interventions, 19 studies); and (3) specific developmental topics (topic specific), including infant colic and reading aloud to children (7 interventions, 9 studies). Descriptions of interventions are found in Tables 1, 2, and 3, which include the intervention components, the “dose” of the intervention, the developmental focus of the intervention, who administered the intervention, the cost when available, and the connection to primary care.

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FIGuRe 1Flowchart for search results through February 14, 2017.


General developmental interventions included the Video Interaction Project (VIP), 17 – 23 Building Blocks (BB), 19 –21, 23 Healthy Steps (HS), 24 – 28 HS plus PrePare (PP), 15, 29 Care For Development (CFD) Intervention, 16, 30 Touchpoints, 31 Play with

Our Children (POC), 32 Parenting Intervention, 33 and Sit Down and Play (SDP).34 VIP and HS were the 2 most intensive interventions involving additional meetings with child development specialists at each well-child visit from birth to age 3 years.

VIP sessions included videotaping the parent and child during a play interaction followed by review and coaching of the interaction with the specialist at a cost of $150 to $240 per child per year. BB provided a monthly newsletter and age-specific



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TABLe 1 Summary and Description of General Developmental Support Interventions (n = 9)

Intervention Brief Description Focus Delivery

VIP Videotaping and coviewing parent-child interaction followed by discussion, developmentally age appropriate toy, and written material

Discussion of developmental concerns, review of video to identify strengths and potential areas of improvement, provide age-appropriate learning material

12 sessions, 30–45 minDelivered by: child development specialistPrimary careCost: $150–240 per child per yearPrimary care: delivered in the primary care clinic

during well-child visitsBB Age-specific newsletter mailed once

per mo with developmentally age-appropriate toy and parent-completed developmental questionnaires

Support of verbal interactions in the context of pretend play, shared reading, and daily routines

Delivered by: not applicable, materials onlyCost: $75 per child per yearPrimary care: materials sent to patients by the

primary care clinic and contacted family if questionnaires suggested possible delay

hS Meeting with developmental specialist, phone lines for questions; written material, parenting groups

Developmental, behavioral, and psychosocial aspects of care

9 enhanced well-child visits and 6 home visits in the first 3 y

Delivered by: child development specialistCost: $400–$933 per childPrimary care: delivered in the primary care clinic

during well-child visitshS + PP Meeting with developmental specialist,

phone support, and screening for risk factors (smoking, depression, domestic violence)

Education and preparation for changes in pregnancy and newborn period, identify risk in pregnant mothers

3 home visits during pregnancy and hSDelivered by: child development specialistPrimary care: hS components delivered in the

primary care clinic during well-child visitsCFD Structured interview and counseling

during an acute health visit and 1 wk follow-up visit15

Enhancement of caregiver-child interactions and home environment in resource-limited settings, introducing forms of play, communication, homemade toys, and reading aloud

2 sessions, 30 min15

Discussion based on counseling guidelines, modeling, practice with feedback, and written material16

2 sessions, 30–60 min16

Delivered by: physician or other health professionalPrimary care: delivered in clinics or by health

professionalsTouchpoints Sessions with a parent coach,

phone support, Ages and Stages Questionnaire activity-based system, video vignettes, and modeling child interactions

Strengthening of parent-health provider relationship, educate about nonharsh parent-child interactions, and increase use of community resources

Clinic and home visits from birth to 18 moDelivered by: “parent coach” (bilingual college-

educated in child development)Primary care: mentoring by social worker and nurse

from the primary care officePoC Group sessions (15 dyads per group),

home visits, and in-depth interviews for parents of children aged 0–4 y

Strengthening positive caregiver-child interaction in learning activities and play; promote comprehensive socioemotional, motor, language, and cognitive development; enhance parenting skills and knowledge; and foster networks among caregivers

Weekly group sessions, 2.5 hDelivered by: “community monitors” with support

from physicians, psychologists, and teachersPrimary care: sessions held in health center, support

from physicians, psychologists

Parenting intervention

Shown short videos (9 modules, 3 min each), discussed and encouraged mother to practice activity shown in video (∼16 min), health provider reinforced messages, gave written materials, a book, and a puzzle

Illustration of mothers doing parenting behaviors considered central to promoting child development

5 brief sessions in waiting roomsDelivered by: community health worker and nursePrimary care: delivered in the primary care clinic

during routine health maintenance visits

SDP Modeling for parents how a toy can facilitate talking or playing with their child. Parents observed and feedback provided on their interaction introducing the new toy.

Informed by social cognitive theory, promoting observational learning, resources to engage in behaviors, and concrete strategies in addition to knowledge provision

8 sessions from 2–24 mo of age, 10–15 min in waiting room

Delivered by: existing clinical staff, nonprofessionals, or volunteers

Primary care: delivered in the primary care clinic waiting room


toy to families at a lower cost ($75) and was studied as part of a 3-arm randomized controlled trial (RCT) with VIP. HS clinic sessions offered parents an opportunity to discuss developmental concerns with a child development specialist as well as

home visits, phone support, written material, and parenting groups. PP was an addition to HS providing 3 home visits during pregnancy. HS cost between $400 and $933 for 11 well-child visits and 2 home visits over 2.5 years. Touchpoints included

similar services (clinic and home visits, phone support) delivered from birth to 18 months of age by a “parent coach” with college-level education in child development. CFD, developed by the World Health Organization and the United Nations



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TABLe 2 Summary and Description of General Behavioral Development Interventions (n = 8)


IY Group sessions (8–12 parents, group discussions after video vignettes, modeling, role play, and parent homework)

Nurture parenting through play, praise, rewards, limit setting, managing misbehavior

6–10 weekly group sessions, 2 hDelivered by: clinical psychologist and 1 pediatric

staff (RN, MD, LCSW, NP)Primary care: delivered at primary care clinics or

public health centersTriple P Level 1: universal parent information

strategy that provides all interested parents with access to useful information via pamphlets and electronic media

(1) enhance parental knowledge and resourcefulness; (2) promote nurturing, low-conflict environments for children; (3) promote children’s social, emotional, and intellectual competencies through positive parenting practices

Delivered by: child development specialist, psychologist, or physician

Level 2: 2 sessions in clinic, early anticipatory developmental guidance, video, and pamphlets

Primary care: delivered in primary care clinics or health centers

Level 3: 4 sessions in clinic, 30 min, for children with mild to moderate behavioral difficulties

Level 4: 8–10 sessions, 2 h, individual, group, or self-directed parent training program for children with more severe behavioral difficulties

Level 5: 12 sessions, 1–2 h, enhanced behavioral family intervention program when behavior is complicated by other sources of family distress

PCIT Compared group sessions (2–4 dyads) and homework reinforcing skills versus providing the same information in written packets

Praise for positive behavior and not giving any attention to negative behavior

4 weekly group sessions, 1.5 hDelivered by: PCIT-trained therapist and the children

with research assistantPrimary care: delivered in primary care clinic

waiting room after hoursUniversal

parenting program/toddlers without tears

Individual sessions with health care provider, handouts describing normal child development

Education regarding unreasonable expectations, harsh discipline, and nurturing parenting

3 sessions, 2 hDelivered by: health care provider and a parenting

expertPrimary care: delivered by physician separate from

usual clinic visits

Webster-Stratton

Group sessions (10 parents per group), videos, group discussion, role play, homework

Improvement of parent-child interactions, limit setting, ignoring undesired behavior, praise, reward, follow through on discipline plans

10 weekly group sessions, 2 hDelivered by: trained health visitors or nursesPrimary care: delivered at health centers

Family Foundations

Group psycho-educational sessions (5 prenatal, 4 postnatal, 8–12 couples per group)

Coparental conflict resolution, problem solving, and communication

9 group sessions, 2–3 hDelivered by: trained male and female facilitatorsPrimary care: delivered at health center

ezParent Modules on an android tablet, adapted from the Chicago parent program group sessions, includes video vignettes, knowledge questions, and interactive games

Evidence-based strategies to encourage good behavior and decrease misbehavior in children aged 2–5 y

6 modules, 1 hDelivered by: electronic devicePrimary care: delivered in large urban primary care

pediatric clinic

PriCARE Weekly group sessions (6–8 parents), includes role-play and homework

Trauma-informed positive parenting, prosocial behaviors, giving effective commands. Informed by attachment and social learning theories and based in PCIT techniques

6 weekly group sessions, 1.5 hDelivered by: 2 licensed mental health professionalsPrimary care: delivered in conference room at

primary care clinic

LCSW, Licensed Clinical Social Worker; MD, Doctor of Medicine; NP, Nurse practitioner; RN, registered nurse.


Children’s Fund and officially called the Care for Child Development intervention, provided a picture card and guides for clinicians to share with parents to discuss the importance of developmentally appropriate play, home-made toys, communication, and reading. POC offered group sessions by “community monitors” as well as home visits and in-depth interviews from birth to age 4 years. The Parenting Intervention and SDP were 2 brief interventions delivered in waiting rooms for 10 to 15 minutes by community health workers or paraprofessional volunteers.

General behavioral interventions included Incredible Years (IY), 35, 36 Positive Parenting Program (Triple P), 37 – 45 Parent-Child Interaction Therapy (PCIT), 46 Universal Parenting Program (also called Toddlers without Tears), 47, 48 Webster-Stratton, 49, 50 Family Foundations, 51 ezParent, 52 and PriCARE.53 Triple P was the most widely disseminated and studied program, which included 9 publications from 4 different countries. Triple P had 5 levels of intervention intensity designed to match the severity of the child’s behavioral problems (Table 2).

With increasing Triple P levels, the total number of sessions as well as length of sessions increased. The Webster-Stratton intervention, IY, and PriCARE were among the more intensive group-based parenting programs involving ∼10 parents in 6 to 10 sessions delivered by child psychologists or pediatric staff, including role play, homework, and group discussion. PriCARE adapted a trauma-informed program called Child-Adult Relationship Enhancement54 on the basis of principles and techniques derived from PCIT for the primary care setting. PCIT and the Universal



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TABLe 3 Summary and Description of Specific Developmental Topic Interventions (n = 7)


Family-centered treatment (colic)

Individual sessions, developed IFTP Identification of potential causes of and responses to infant colic, develop coping mechanisms to deal with crying

3 sessions within 6 wkDelivered by: pediatrician and mental health

specialistPrimary care: delivered in the primary care clinic

BBP (colic) Booklets and video mailed to parents, optional phone call and group parenting session

Development of a tailored management plan to address infant crying

25 min video, 1 group session 1.5 hDelivered by: maternal child health nursesCost: $60Primary care: overseen by pediatrician at respective

health centersThB (colic) Video for parents describing the best

way to calm their infant on the basis of a step-wise approach beginning with feeding, then holding, changing, swaddling, side-laying, swaying, exposing to white noise, and then pacifier

Strategies to soothe crying infant 30 min videoDelivered by: multimedia videoPrimary care: delivered in community hospitals on

the newborn nursery, assume cared provided by general pediatricians

Infant massage (colic)

Mothers learned to administer infant massage during 1 session, then massaged infants once during the day and once at night before sleeping. Control group was rocked gently for 5–25 min

Infant massage for soothing 1 session, daily massage 15–20 minDelivered by: training by expert in infant massage,

massage administered by mothersPrimary care: training provided in clinic

Literacy promoting intervention (reading)

Families given an age appropriate book and written handout explaining benefits of reading to children

Child literacy and parent-child interactions

Each well-child visit from 6–18 moDelivered by: pediatric providersPrimary care: delivered in the primary care clinic

during well-child visitsRoR (reading) Reading demonstrations of age-

appropriate books, anticipatory guidance, written material, and age-appropriate book written in English

Child literacy and parent-child interactions

Each well-child visit from 6 mo to 6 yDelivered by: volunteer (demonstration) and

physician (anticipatory guidance)Primary care: delivered in the primary care clinic

waiting roomsRoR + M Modeling how parents could use a

developmentally appropriate book to engage the child in mathematics activities around specific concepts (discriminating small numbers of objects, counting, simple arithmetic, geometry, spatial thinking) by using mathematical language and written handout focused on each concept

Child literacy, parent-child interactions, and promotion of basic math skills

1 session at a well-child visitDelivered by: pediatric residentsPrimary care: delivered in the primary care clinic

BBP, Baby Business Program; IFTP, Individualized Family Treatment Plan; ThB, The happiest Baby.


Parenting Program required fewer sessions (3–4) ranging from 1.5 to 2.5 hours. Family Foundations included psycho-education for coparents to resolve conflicts between parents beginning prenatally. EzParent was the only behavioral intervention that was entirely delivered via an electronic device, adapting a parenting group curriculum into 6 multimedia interactive modules.

The topic-specific interventions included 4 interventions for colic (Family-Centered Treatment, 55 Baby Business Program, 56 The Happiest Baby, 57 and Infant Massage58) and 3 interventions to promote reading aloud (Literacy Promotion Intervention, 59 Reach Out and Read [ROR], 6, 60, 61 and Reach Out and Read plus Mathematics [ROR + M]62). The 4 colic interventions varied greatly in intensity from development of individualized family treatment plans designed by a pediatrician and mental health specialist (Family-Centered Treatment) to multimedia videos with optional discussion (Baby Business Program and The Happiest Baby) as well as infant massage. ROR is a well-studied program to promote child literacy during well-child visits, also previously described in Regalado and Halfon’s4 review. The authors of 2 additional studies completed after 1999 evaluated the intervention through a quality improvement evaluation across 10 states in the United States.6, 60 The authors of a third study modified the intervention to teach specific math topics.62 A literacy intervention similar to ROR evaluated the impact of reading aloud on receptive and expressive language development.59

sample Composition

The authors of the studies included in this review recruited participants from varying socioeconomic backgrounds, ethnicities, and nationalities. VIP involved primarily low-income and Spanish-speaking participants in the United States,

a large proportion of which did not receive education beyond the seventh grade. HS studies included 15 primary care sites across the United States.25 – 27 Three interventions (CFD, POC, and the Parenting Intervention) were studied solely in low- or middle-income countries. In contrast to the general developmental interventions, behavioral interventions tended to target participants on the basis of behavioral concerns rather than demographic factors. The researchers for IY, 35, 36 Webster-Stratton, 49, 50 and PriCARE53 studies enrolled children that scored above a certain threshold on behavioral assessments or whose parents reported concerns regarding their child’s behavior. Triple P tailored the intervention intensity on the basis of the severity of the child’s behavioral problems.

Levels of evidence

General developmental interventions were primarily conducted as quasi-experimental study designs, with the exception of the VIP and the Parenting Intervention studies in which RCTs were employed (Table 4). Sample sizes ranged from 50 at a single site31 to >3000 study participants in 10 sites.25, 26 All of the general behavioral interventions were evaluated by at least 1 RCT (Table 5). For topic-specific studies, RCT study design was employed in colic interventions, whereas observational cohorts or cross-sectional comparisons with historical controls were used in the literary studies (Table 6). All Levels of Evidence scores are reported in Tables 4 through 6.

Outcomes

General Developmental Support

Among the general developmental interventions, cohorts enrolled in HS and VIP experienced fewer cases of developmental delay compared with control groups at 12 months28 and 3 years, respectively.17, 18 The effects

of VIP on child development were more pronounced among children of mothers with seventh to 11th grade educations in 1 study17, 18 and for mothers with a literacy level of ninth grade or higher in a second study.19 VIP also resulted in decreased hyperactivity and externalizing behaviors.23 HS and PP resulted in a reduction in child aggressive behavior at 30 months of age measured by the Child Behavior Checklist (CBCL).15, 29 No difference in child behavior was detected with HS alone. CFD resulted in improved adaptive, language, and social development 6 months postintervention.30 Touchpoints was associated with significant improvement in child language development (expressive and receptive) measured by the MacArthur Communicative Development Inventories at 16 months of age.31 The Parenting Intervention was associated with significantly improved cognitive development (Griffith Mental Development Scale), but not specifically language development.33

Multiple studies reported significant changes in both parenting behaviors and psychological well-being. Parents enrolled in the VIP, 19 BB, 19 HS, 25, 26 CFD, 16 and SDP34 interventions engaged in educational activities (such as reading) at significantly higher levels compared with control groups. The overall quality of the home environment improved among families enrolled in VIP and BB at 6 months of age.19 HS, 24 Touchpoints, 31 and POC32 were associated with greater parental sensitivity and higher quality parent-child interactions. Parents enrolled in VIP reported significantly reduced stress and depressive symptoms compared with controls.22 One study in which HS and PP were evaluated revealed an increase in parental depressive symptoms and a decrease in parenting satisfaction among the intervention group at 30 months.15, 29



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TABL

e 4

Gene

ral D

evel

opm

enta

l Sup

port

Inte

rven

tions

: Res

ults

and

Lev

els

of E

vide

nce

Inte

rven

tion

Refe

renc

eSt

udy

Desi

gnSa

mpl

e Si

ze, L

ocat

ion

Age,

Spe

cific

Pop

ulat

ion

Leve

ls o

f Evi

denc

eEf

fect

Child

out

com

esPa

rent

out

com

es

VIP,

Men

dels

ohn

et a

l17, 18

RCT

N =

99, N

ew Y

ork,

NY

Birt

h to

36

mo

low

in

com

e fa

mili

es,

mos

tly h

ispa

nic

1Si

gnifi

cant

ly fe

wer

cas

es o

f de

velo

pmen

tal d

elay

(BS

ID).

No

chan

ge in

lang

uage

(PL

S-3)

or

beha

vior

(CB

CL)

at 2

1 an

d 33

mo

of a

ge.

Sign

ifica

ntly

red

uced

par

entin

g st

ress

(P

SI-S

F) a

nd im

prov

ed p

aren

tal

teac

hing

(PI

DA),

no c

hang

e in

de

pres

sion

(CE

S-D)

or

the

hom

e en

viro

nmen

t (St

imQT

) at

33

mo

of

age

VIP

3-ar

m R

CTN

= 41

0, N

ew Y

ork,

NY

Birt

h to

36

mo

low

in

com

e fa

mili

es,

mos

tly h

ispa

nic

1Im

prov

ed a

tten

tion

at 2

4 m

o,

decr

ease

d hy

pera

ctiv

ity a

nd

exte

rnal

izin

g be

havi

ors

at 3

6 m

o of

age

Impr

oved

qua

lity

of th

e ho

me

envi

ronm

ent (

Stim

QI)

and

incr

ease

d tim

e sp

ent r

eadi

ng (

read

ing

diar

y)

at 6

mo

of a

geM

ende

lsoh

n et

al19

Berk

ule

et a

l20Re

duct

ion

in m

ild a

nd m

oder

ate

depr

essi

ve s

ympt

oms

(PhQ

-9)

at 6

m

o of

age

Canfi

eld

et a

l21De

crea

sed

pare

ntin

g st

ress

(PS

I-SF)

Cate

s et

al, 22

Wei

sled

er

et a

l23At

6, 2

4, a

nd 3

6 m

o

Less

har

sh d

isci

plin

e at

24

mo

of a

geBB

, Men

dels

ohn

et a

l, 19

Berk

ule

et a

l203-

arm

RCT

N =

410,

New

Yor

k, N

YBi

rth

to 3

6 m

o lo

w

inco

me

fam

ilies

, m

ostly

his

pani

c

1No

diff

eren

ce in

att

entio

n or

imita

tion

play

at 2

4 m

oIm

prov

ed q

ualit

y of

the

hom

e en

viro

nmen

t (St

imQI

) at

6 m

o of

age

Canfi

eld

et a

l, 21 W

eisl

eder

et

al23

Incr

ease

d no

. rea

ding

inst

ance

s pe

r da

y (r

eadi

ng d

iary

)Re

duct

ion

in m

ild d

epre

ssiv

e sy

mpt

oms

(PhQ

-9)

at 6

mo

of a

geNo

cha

nge

in h

arsh

dis

cipl

ine

at 2

4 m

ohS

, Cau

ghy

et a

l24RC

TN

= 37

8, S

outh

east

an

d So

uthw

est,

Unite

d St

ates

Birt

h to

36

mo

1No

diff

eren

ces

in b

ehav

ior

(CBC

L) a

t 34

–37

mo

of a

geGr

eate

r pa

rent

al s

ensi

tivity

(NC

AST)

, le

ss h

arsh

dis

cipl

ine,

and

hig

her

qual

ity p

aren

ting

inte

ract

ions

(P/

CIS)

at 3

4–37

mo.

No

diffe

renc

e in

th

e ho

me

envi

ronm

ent (

hoM

E)h S

RCT

6 si

tes,

qua

si-

expe

rim

enta

l 9 s

ites

N =

3165

, Uni

ted

Stat

esBi

rth

to 3

6 m

o2

No s

igni

fican

t diff

eren

ce in

ag

gres

sive

or

anxi

ous

beha

vior

(C

BCL)

Less

sev

ere

disc

iplin

e an

d gr

eate

r re

port

ed r

eadi

ng a

ctiv

ities

with

ch

ild a

t 62

mo.

Gre

ater

igno

ring

ch

ild m

isbe

havi

or a

t 36

mo,

but

not

at

62

mo

Min

kovi

tz e

t al25

, 26

Zuck

erm

an e

t al27

At 3

6 m

o of

age

hS, N

iede

rman

et a

l28Co

hort

N =

363,

Chi

cago

, IL

Birt

h to

36

mo

3Si

gnifi

cant

ly fe

wer

cas

es o

f de

velo

pmen

tal d

elay

(ch

art r

evie

w)

at 1

2 m

o po

stin

terv

entio

n

None

rep

orte

d




2017



December 2017

140

Inte

rven

tion

Refe

renc

eSt

udy

Desi

gnSa

mpl

e Si

ze, L

ocat

ion

Age,

Spe

cific

Pop

ulat

ion

Leve

ls o

f Evi

denc

eEf

fect

Child

out

com

esPa

rent

out

com

eshS

+ P

P, J

ohns

ton

et a

l15, 29

3-ar

m q

uasi

-ex

peri

men

tal

N =

439,

Pac

ific

Nort

hwes

t, Un

ited

Stat

es

Birt

h to

36

mo

mos

tly

high

er in

com

e fa

mili

es

2Re

duce

d ag

gres

sive

beh

avio

r (C

BCL)

at

30

mo

post

inte

rven

tion

Redu

ced

mat

erna

l dep

ress

ion

sym

ptom

sco

res

(CES

-D)

at 3

mo

but

high

er d

epre

ssio

n sc

ores

and

low

er

pare

nt s

atis

fact

ion

(PSo

C) a

mon

g in

terv

entio

n gr

oup

at 3

0 m

oNo

diff

eren

ce in

lang

uage

de

velo

pmen

t (M

CDI)

or a

nxio

us

beha

vior

(CB

CL)

at 3

or

30 m

o po

stin

terv

entio

n

No d

iffer

ence

in n

urtu

ring

inte

ract

ions

, pa

rent

sel

f-effi

cacy

(PS

oC)

CFD,

Ert

em e

t al16

Sequ

entia

lly c

ondu

cted

co

ntro

l tri

alN

= 23

3, A

nkar

a,

Turk

eyBi

rth

to 2

3 m

o lo

w

to m

iddl

e in

com

e fa

mili

es

2No

ne r

epor

ted

Incr

ease

d no

. of f

amily

mad

e to

ys,

RR =

4.0

(2.

3, 7

.1),

and

read

ing

to

child

, RR

= 5.

6 (2

.0, 1

5.8)

, at 1

mo

post

inte

rven

tion.

No

diffe

renc

e in

qua

lity

of th

e ho

me

lear

ning

en

viro

nmen

t (ho

ME)

CFD,

Jin

et a

l30Qu

asi-e

xper

imen

tal

N =

100,

Anh

ui, C

hina

Birt

h to

24

mo

low

in

com

e fa

mili

es, r

ural

2Im

prov

ed a

dapt

ive,

lang

uage

and

so

cial

dev

elop

men

t (GS

) 6

mo

post

inte

rven

tion

None

rep

orte

d

No d

iffer

ence

in m

otor

dev

elop

men

tTo

uchp

oint

s, F

arbe

r31Qu

asi-e

xper

imen

tal

N =

50, W

ashi

ngto

n,

DCBi

rth

to 1

8 m

o lo

w

inco

me

fam

ilies

2Im

prov

ed r

ecep

tive

and

expr

essi

ve

lang

uage

dev

elop

men

t (M

CDI)

at

exit

(ave

rage

age

16

mo)

Grea

ter

posi

tive

pare

ntin

g (A

API)

and

resi

lienc

e sc

ores

(RA

S) a

t exi

t (a

vera

ge a

ge 1

6 m

o)Po

C, B

rahm

et a

l32Qu

asi-e

xper

imen

tal

N =

102,

San

tiago

, Ch

ile2–

23 m

o lo

w in

com

e fa

mili

es2

None

rep

orte

dDe

crea

sed

mat

erna

l str

ess

(PSI

-SF)

for

child

ren

<12

mo

of a

ge, i

ncre

ased

m

ater

nal s

ensi

tivity

(Q-

Sort

) fo

r ch

ildre

n ag

ed 1

2–23

mo.

No

diffe

renc

e in

mat

erna

l dep

ress

ion

(PhQ

-9)

imm

edia

tely

aft

er

inte

rven

tion

Pare

ntin

g in

terv

entio

n,

Chan

g et

al33

Clus

ter

RCT

N =

501,

Jam

aica

, An

tigua

, St.

Luci

a3–

18 m

o1

Impr

ovem

ent i

n co

gniti

ve

deve

lopm

ent s

core

(GM

DS)

at 1

8 m

o of

age

Impr

oved

par

entin

g kn

owle

dge,

no

chan

ge in

par

entin

g be

havi

ors

(hoM

E) a

t 18

mo

of a

ge. N

o ch

ange

in

mat

erna

l dep

ress

ive

sym

ptom

s (C

ES-D

) at

18

mo

of a

geNo

diff

eren

ce in

lang

uage

de

velo

pmen

t (CD

I) at

18

mo

of a

geSD

P, S

hah

et a

l34Pr

ospe

ctiv

e co

hort

stu

dyN

= 30

, Chi

cago

, IL

6–12

mo

low

inco

me

fam

ilies

, Afr

ican

Am

eric

an o

r hi

span

ic

2No

ne r

epor

ted

Impr

oved

par

enta

l ver

bal

resp

onsi

vene

ss, a

nd p

aren

tal

invo

lvem

ent (

Stim

Q) a

t 4 w

k po

stin

terv

entio

n

AAPI

, Adu

lt-Ad

oles

cent

Par

entin

g In

vent

ory;

BSI

D, B

ayle

y Sc

ales

of I

nfan

t Dev

elop

men

t; CD

I, Co

mm

unic

ativ

e De

velo

pmen

t Inv

ento

ry; C

ES-D

, Cen

ter

for

Epid

emio

logi

c St

udie

s-De

pres

sion

Sca

le; G

MDS

, Gri

ffith

Men

tal D

evel

opm

ent S

cale

; GS,

Ges

ell S

cale

; ho

ME,

hom

e ob

serv

atio

n fo

r M

easu

rem

ent o

f the

Env

iron

men

t Inv

ento

ry; M

CDI,

Mac

Arth

ur C

omm

unic

ativ

e De

velo

pmen

t Inv

ento

ries

; NCA

ST, N

ursi

ng C

hild

Ass

essm

ent b

y Sa

telli

te T

rain

ing;

P/C

IS, P

aren

t/Ca

regi

ver

Invo

lvem

ent S

cale

; PhQ

-9, P

atie

nt

heal

th Q

uest

ionn

aire

-9; P

IDA,

Par

enta

l Inv

olve

men

t in

Deve

lopm

enta

l Adv

ance

men

t; PL

S-3,

Pre

scho

ol L

angu

age

Scal

e-3;

PSI

-SF,

Pare

ntin

g St

ress

Inde

x-Sh

ort F

orm

; PSo

C, P

aren

ting

Sens

e of

Com

pete

nce

Scal

e; R

AS, R

esili

ency

Att

itude

Sca

le; R

R, r

elat

ive

risk

; Stim

Q, a

val

idat

ed in

terv

iew

-bas

ed in

stru

men

t for

mea

sure

men

t of a

fam

ily’s

cog

nitiv

e ho

me

envi

ronm

ent;

Stim

QI, S

timQ

Infa

nt; S

timQT

, Stim

Q To

ddle

r.

TABL

e 4

Cont

inue

d




2017



December 2017

140

TABL

e 5

Gene

ral B

ehav

iora

l Dev

elop

men

t Int

erve

ntio

ns: R

esul

ts a

nd L

evel

s of

Evi

denc

e

Inte

rven

tion,

Ref

eren

ceSt

udy

Desi

gnSa

mpl

e Si

ze, L

ocat

ion

Age,

Spe

cific

Pop

ulat

ion

Leve

ls o

f Evi

denc

eEf

fect

Child

out

com

esPa

rent

out

com

es

IY, R

eedt

z et

al35

RCT

N =

186,

Tro

mso

, No

rway

2–8

y1

Decr

ease

in b

ehav

ior

inte

nsity

(E

CBI-I

S) im

med

iate

ly a

fter

in

terv

entio

n, n

o di

ffere

nce

at 1

2 m

o po

stin

terv

entio

n

Redu

ced

use

of h

arsh

dis

cipl

ine

(PPI

), im

prov

ed p

ositi

ve p

aren

ting

(PPI

), pa

rent

sat

isfa

ctio

n at

12

mo

post

inte

rven

tion

Mea

n ag

e: 3

.9 y

high

beh

avio

ral i

nten

sity

No d

iffer

ence

in p

aren

ting

self-

effic

acy

(PSo

C)IY

, Per

rin

et a

l36RC

T an

d di

rect

as

sign

men

tN

= 17

3, G

reat

er B

osto

n ar

ea, U

nite

d St

ates

2–4

y1

Redu

ced

beha

vior

pro

blem

s an

d in

tens

ity (

ECBI

-IS)

at 6

and

12

mo

post

inte

rven

tion

Redu

ced

obse

rved

neg

ativ

e pa

rent

-ch

ild in

tera

ctio

n–su

ppor

tiven

ess/

nurt

urin

g (D

PICS

-R)

and

redu

ced

self-

repo

rted

neg

ativ

e pa

rent

ing

(PS)

at 1

2 m

oPo

or s

ocia

l-em

otio

nal

deve

lopm

ent

No d

iffer

ence

in o

bser

ved

disr

uptiv

e be

havi

or (

DPIC

S-R)

No d

iffer

ence

in o

bser

ved

nega

tive

pare

ntin

g–pa

rent

neg

ativ

ity/

host

ility

(DP

ICS-

R) a

t 12

mo

post

inte

rven

tion

Trip

le P

leve

l 2 &

3,

McC

onne

ll et

al37

Quas

i-exp

erim

enta

lN

= 92

3, A

lber

ta,

Cana

daBi

rth–

11 y

, mea

n ag

e: 2

.8 y

2No

ne r

epor

ted

No s

igni

fican

t diff

eren

ce in

per

sona

l di

stre

ss o

r ch

ild r

eari

ng d

istr

ess

(PSI

-SF)

, or

fam

ily fu

nctio

ning

(N

LSCY

) at

8–1

2 w

k po

stin

terv

entio

nTr

iple

P le

vel 3

, Tur

ner

and

Sand

ers38

RCT

N =

30, B

risb

ane,

Au

stra

lia2–

6 y,

mea

n ag

e: 3

.3 y

1Re

duce

d be

havi

or p

robl

ems

(PDR

, EC

BI-P

S, h

CPC)

, int

ensi

ty (

ECBI

-IS)

at 6

mo

post

inte

rven

tion

Impr

oved

dis

cipl

ine

styl

e (P

S) a

nd

satis

fact

ion

(PSo

C) a

t 6 m

o po

stin

terv

entio

nFa

mily

req

uest

ing

advi

ceNo

diff

eren

ce in

chi

ld d

isru

ptiv

e be

havi

or (

FoS)

No d

iffer

ence

in p

aren

t sel

f-effi

cacy

(P

CoS)

, pos

itive

par

entin

g (F

oS),

mat

erna

l dep

ress

ion,

anx

iety

, or

stre

ss (

DASS

)Tr

iple

P le

vel 3

, McC

orm

ick

et a

l39RC

TN

= 10

1, S

eatt

le, W

A1.

5–12

y1

No d

iffer

ence

in c

hild

beh

avio

r (C

BCL)

at 3

mo

post

inte

rven

tion.

No d

iffer

ence

in d

isci

plin

e (C

DS),

pare

nt s

atis

fact

ion

or s

elf-e

ffica

cy

(PCo

S) a

t 3 m

o po

stin

terv

entio

nM

ean

age:

4.8

yTr

iple

P le

vel 4

, Leu

ng

et a

l40RC

TN

= 69

, hon

g Ko

ng,

Chin

a3–

7 y

1Im

prov

ed b

ehav

ior

prob

lem

s (P

DR,

ECBI

-PS)

, int

ensi

ty (

ECBI

-IS),

cond

uct,

emot

ion,

hyp

erac

tivity

, an

d pe

er in

tera

ctio

ns (

SDQ)

im

med

iate

ly a

fter

inte

rven

tion

Impr

oved

sel

f-rep

orte

d di

scip

line

styl

e (P

S), p

aren

t sat

isfa

ctio

n, s

elf-

effic

acy

(PCo

S), a

nd m

arita

l hea

lth

(RQI

) im

med

iate

ly a

fter

inte

rven

tion

Mea

n ag

e: 4

.2 y




2017



December 2017

140

Inte

rven

tion,

Ref

eren

ceSt

udy

Desi

gnSa

mpl

e Si

ze, L

ocat

ion

Age,

Spe

cific

Pop

ulat

ion

Leve

ls o

f Evi

denc

eEf

fect

Child

out

com

esPa

rent

out

com

esTr

iple

P le

vel 4

, Leu

ng

et a

l41Co

hort

stu

dyN

= 48

0, h

ong

Kong

, Ch

ina

3 y

old

low

inco

me

fam

ilies

, chi

ld b

ehav

ior

prob

lem

3Im

prov

ed b

ehav

iora

l int

ensi

ty

(ECB

I) im

med

iate

ly

post

inte

rven

tion

Impr

oved

par

enta

l sat

isfa

ctio

n,

self-

effic

acy

(PSo

C), d

ecre

ased

pa

rent

ing

stre

ss (

PSI)

and

depr

essi

on, a

nxie

ty o

r st

ress

sy

mpt

oms

(DAS

S) im

med

iate

ly

post

inte

rven

tion

Trip

le P

leve

l 4, Z

ubri

ck

et a

l42Qu

asi-e

xper

imen

tal

N =

1610

, Wes

tern

Au

stra

lia36

–48

mo

2Im

prov

ed b

ehav

ior

inte

nsity

(E

CBI-I

S) a

t 12

and

24 m

o po

stin

terv

entio

n

Impr

oved

sel

f-rep

orte

d di

scip

line

styl

e (P

S), m

enta

l hea

lth (

DASS

), pa

rent

al

confl

ict d

ue to

par

entin

g (P

PC),

and

mar

ital h

ealth

(AD

AS)

at 1

2 an

d 24

m

o po

stin

terv

entio

nM

ean

age:

45

mo

Trip

le P

leve

l 4 a

nd 5

, Sa

nder

s et

al43

, 444

arm

RCT

No

cont

rol

beyo

nd 1

5 w

kN

= 30

5, B

risb

ane,

Au

stra

lia36

–48

mo

2Im

prov

ed d

isru

ptiv

e be

havi

or (

PDR)

an

d be

havi

oral

inte

nsity

(EC

BI)

at

12 m

o an

d 3

y po

stin

terv

entio

n.

No d

iffer

ence

bet

wee

n tr

eatm

ent

grou

ps

Impr

oved

par

ent c

ompe

tenc

e (P

CoS)

, di

scip

line

(PS)

, and

mar

ital c

onfli

ct

at 3

y. N

o di

ffere

nce

at 1

2 m

o po

stin

terv

entio

n

Mea

n ag

e: 4

1 m

oLo

w in

com

e fa

mili

es, h

igh

beha

vior

al in

tens

ityNo

diff

eren

ce in

dep

ress

ion,

anx

iety

, or

str

ess

(DAS

S) fo

r m

othe

rs o

r fa

ther

s at

12

mo

post

inte

rven

tion

Trip

le P

leve

l 4 a

nd 5

, Can

n et

al45

Coho

rt s

tudy

N =

589,

Mel

bour

ne,

Aust

ralia

1–15

y, m

ean

age:

4.5

y3

Impr

oved

beh

avio

ral i

nten

sity

an

d re

duce

d be

havi

or

prob

lem

s (E

CBI)

imm

edia

tely

po

stin

terv

entio

n.

Redu

ctio

n in

dys

func

tiona

l par

enta

l st

yles

(PS

), im

prov

ed p

aren

tal

satis

fact

ion

and

self-

effic

acy

(PCo

S),

impr

oved

dep

ress

ion,

anx

iety

, an

d st

ress

sym

ptom

s (D

ASS)

im

med

iate

ly p

ostin

terv

entio

nPa

rent

-chi

ld in

tera

ctio

n th

eory

, Ber

kovi

ts e

t al46

RCT

N =

30, G

aine

svill

e, F

L3–

6 y

1Im

prov

ed b

ehav

ior

inte

nsity

(EC

BI-

IS)

at 6

mo

post

inte

rven

tion

Impr

oved

sel

f-rep

orte

d co

nfide

nce

(PLo

C-SF

) an

d di

scip

line

styl

e (P

S)

at 6

mo

post

inte

rven

tion.

Univ

ersa

l par

entin

g pr

ogra

m/t

oddl

ers

with

out t

ears

, his

cock

et

al, 47

Bay

er e

t al48

Clus

ter

RCT

N =

733,

Mel

bour

ne,

Aust

ralia

8 m

o1

No d

iffer

ence

in e

xter

naliz

ing

or

inte

rnal

izin

g be

havi

ors

(CBC

L) a

t 10

, 16,

or

28 m

o of

age

Decr

ease

d un

reas

onab

le e

xpec

tatio

ns

(PBC

) at

16

and

28 m

o. D

ecre

ased

ha

rsh

disc

iplin

e (P

BC)

at 1

6 m

o, b

ut

not a

t 28

mo

of a

geNo

diff

eren

ce in

nur

turi

ng b

ehav

iors

(P

BC),

mat

erna

l dep

ress

ion,

anx

iety

, or

str

ess

(DAS

S)W

ebst

er-S

trat

ton,

Pa

tter

son

et a

l, 49

Stew

art-B

row

n et

al50

RCT

N =

116,

oxf

ord,

En

glan

d2–

8 y

1De

crea

sed

beha

vior

and

con

duct

pr

oble

ms

(SDQ

) at

6 m

o, b

ut n

ot

at 1

2 m

o po

stin

terv

entio

n. N

o di

ffere

nce

in b

ehav

ior

inte

nsity

(E

CBI-I

S), e

mot

ion,

hyp

erac

tivity

, or

pee

r in

tera

ctio

n

Redu

ctio

n in

dep

ress

ive

sym

ptom

s (G

hQ)

at 1

2 m

o po

stin

terv

entio

n

Mea

n ag

e: 4

.6 y

TABL

e 5

Cont

inue

d


General Behavioral Development

Four interventions resulted in decreased behavioral intensity between 2 and 24 months after the intervention: IY, 35, 36 Triple P levels 3 and 4, 38, 40 – 45 PCIT, 46 and PriCARE.53 Children engaged in the Webster-Stratton intervention exhibited fewer behavioral problems at 6 months, but this difference did not persist at the 12-month follow-up.49, 50 The Universal Parenting Program47, 48 and ezParent52 did not result in any difference in child behavior between the intervention and control groups.

A number of the behavioral interventions also affected parenting behaviors and psychological outcomes. IY resulted in improved positive parenting behaviors 12 months postintervention, 35, 36 and multiple interventions (IY, Triple P level 3 and 4, 38, 40, 42 PCIT, 46 and PriCARE53) led to reductions in the use of harsh discipline. Parental satisfaction, 35, 40, 41 self-efficacy, 40, 41, 43, 44 or confidence46 improved significantly with 3 different interventions, and marital health improved w, ith Triple P40 – 42 and Family Foundations.51 Although in most studies assessed parent mental health, only the Webster-Stratton49, 50 intervention and Family Foundations51 were associated with a reduction in depressive symptoms beyond 10 months postintervention.

Specific Developmental Topic

All 3 interventions designed to address infant colic revealed improvement in colic symptoms in short-term follow-up, but they resulted in mixed results beyond 2 months postintervention (Table 6). The Baby Business Program was also associated with lower maternal depressive symptom scores at 6 months postintervention.56 In contrast, The Happiest Baby video was associated with higher parental stress scores at 12 weeks postintervention.57



2017



December 2017

140

Inte

rven

tion,

Ref

eren

ceSt

udy

Desi

gnSa

mpl

e Si

ze, L

ocat

ion

Age,

Spe

cific

Pop

ulat

ion

Leve

ls o

f Evi

denc

eEf

fect

Child

out

com

esPa

rent

out

com

esCh

ild b

ehav

ior

prob

lem

No d

iffer

ence

in to

tal m

enta

l hea

lth

scor

es (

GhQ)

or

pare

ntin

g st

ress

(P

SI)

Fam

ily F

ound

atio

n,

Fein

berg

et a

l51RC

T In

tent

ion

to T

reat

N =

399,

Uni

ted

Stat

esBi

rth

to 1

0 m

o m

iddl

e cl

ass,

mos

tly w

hite

1Im

prov

ed p

aren

t rep

orte

d so

otha

bilit

y, d

ecre

ased

nig

ht

wak

ing

at 1

0 m

o of

age

Impr

oved

pos

itive

cop

aren

ting

and

com

mun

icat

ion

(obs

erve

d),

and

qual

ity o

f mar

riag

e (Q

MI),

de

crea

sed

depr

essi

on (

CES-

D) a

nd

anxi

ety

sym

ptom

s (P

SWQ)

at 1

0 m

o of

age

ezPa

rent

, Bre

itens

tein

et

al52

RCT

N =

79, C

hica

go, I

L2–

5 y

low

-inco

me

fam

ilies

, m

ostly

Afr

ican

Am

eric

an

or L

atin

o

1No

diff

eren

ce in

chi

ld b

ehav

ior

(ECB

I) at

6 m

o po

stin

terv

entio

nNo

diff

eren

ce in

par

entin

g be

havi

or

(PQ)

, sel

f-effi

cacy

(TC

Q), o

r st

ress

(P

SI-S

F) a

t 6 m

o po

stin

terv

entio

nPr

iCAR

E, S

chill

ing

et a

l53RC

TN

= 12

0, P

hila

delp

hia,

PA

2–6

y1

Decr

ease

d be

havi

or p

robl

ems

(ECB

I) at

7 w

k po

st in

terv

entio

nIn

crea

sed

pare

ntal

em

path

y (A

API2

) an

d de

crea

sed

hars

h di

scip

line

at 7

w

k po

stin

terv

entio

nM

ean

age:

4.3

yLo

w in

com

e, c

hild

beh

avio

r pr

oble

m

AAIP

2, A

dult

Adol

esce

nt P

aren

ting

Inve

ntor

y –

2; A

DAS,

Abb

revi

ated

Dya

dic

adju

stm

ent s

cale

; CDS

, Chi

ld D

isci

plin

e Su

rvey

; CES

-D, C

ente

r fo

r Ep

idem

iolo

gic

Stud

ies-

Depr

essi

on S

cale

; DAS

S, D

epre

ssio

n-An

xiet

y-St

ress

Sca

le; D

PICS

-R, D

yadi

c Pa

rent

-Chi

ld

Inte

ract

ive

Codi

ng S

yste

m–R

evis

ed; E

CBI-I

S, E

yber

g Ch

ild B

ehav

ior

Inve

ntor

y-In

tens

ity S

cale

; ECB

I-PS,

Eyb

erg

Child

Beh

avio

r In

vent

ory-

Prob

lem

Sca

le; F

oS, F

amily

obs

erva

tion

Sche

dule

; GhQ

, Gen

eral

hea

lth Q

uest

ionn

aire

; hCP

C, h

ome

and

Com

mun

ity

Prob

lem

Che

cklis

t; NL

SCY,

Nat

iona

l Lon

gitu

dina

l Sur

vey

of C

hild

ren

and

Yout

h; P

BC, P

aren

t Be

havi

or C

heck

list;

PDR,

Par

ent

Daily

Rep

ort;

PLoC

-SF,

Pare

ntin

g Lo

cus

of C

ontr

ol S

hort

For

m; P

PC, P

aren

t Pr

oble

m C

heck

list;

PPI,

Pare

ntin

g Pr

actic

es

Inte

rvie

w; P

Q, P

aren

ting

Ques

tionn

aire

; PS,

Par

entin

g Sc

ale;

PSI

, Par

entin

g St

ress

Inde

x; P

SI-S

F, Pa

rent

ing

Stre

ss In

dex

Shor

t For

m; P

SoC,

Par

entin

g Se

nse

of C

ompe

tenc

e; P

SWQ,

Pen

n St

ate

Wor

ry Q

uest

ionn

aire

; QM

I, Qu

ality

of M

arri

age

Inde

x; R

QI,

Rela

tions

hip

Qual

ity In

dex;

SDQ

, Str

engt

h an

d Di

fficu

lty S

cale

; TCQ

, Tod

dler

Car

e Qu

estio

nnai

re.

TABL

e 5

Cont

inue

d




2017



December 2017

140

TABL

e 6

Spec

ific

Deve

lopm

enta

l Top

ic In

terv

entio

ns: R

esul

ts a

nd L

evel

s of

Evi

denc

e

Inte

rven

tion,

Ref

eren

ceSt

udy

Desi

gnSa

mpl

e Si

ze, L

ocat

ion,

Ag

eAg

e, S

peci

fic P

opul

atio

nLe

vels

of E

vide

nce

Effe

ct

Child

out

com

esPa

rent

out

com

es

Fam

ily-c

ente

red

trea

tmen

t, Sa

lisbu

ry

et a

l55

RCT

N =

62, U

nite

d St

ates

4–8

wk

1De

crea

sed

child

cry

ing

(h/d

) at

6 w

k an

d tim

e sp

ent f

eedi

ng a

t 6 a

nd 1

0 w

k po

stin

terv

entio

n

No d

iffer

ence

in m

ater

nal d

epre

ssiv

e sy

mpt

oms

(BDI

) or

str

ess

(PSI

) at

6

or 1

0 w

k po

stin

terv

entio

nIn

fant

s w

ith c

olic

, mos

tly

whi

teNo

diff

eren

ce in

tota

l h o

f sle

ep p

er d

BBP,

his

cock

et a

l56RC

TN

= 77

0, M

elbo

urne

, Au

stra

lia4–

13 w

k1

Decr

ease

d cr

ying

sev

erity

at 4

mo

of

age

and

few

er c

hang

ed fo

rmul

a at

6

mo

of a

ge. N

o di

ffere

nce

in s

leep

pr

oble

ms

or d

urat

ion

Decr

ease

d m

ater

nal d

oubt

at 4

mo

of

age,

and

dep

ress

ive

sym

ptom

s at

6

mo

of a

ge

high

inco

me

fam

ilies

No d

iffer

ence

in s

leep

qua

lity,

m

ater

nal a

nger

, saf

ety,

or

limit

sett

ing

T hB,

McR

ury

and

Zolo

tor57

RCT

N =

35, C

olum

bus,

oh

New

born

mid

dle

to h

igh

inco

me

fam

ilies

1No

diff

eren

ce in

cry

ing

(h/d

) or

sle

ep

(h/d

) at

6 o

r 12

wk

of a

geGr

eate

r pa

rent

al s

tres

s (P

SI)

in th

e in

terv

entio

n gr

oup

at 1

2 w

k of

age

Infa

nt m

assa

ge, S

heid

aei

et a

l58RC

TN

= 10

0 Ir

an<1

2 w

k1

Decr

ease

sev

erity

of c

olic

(VA

S),

dura

tion

of c

ryin

g (m

in/d

), an

d in

crea

sed

dura

tion

of s

leep

(m

in/d

) 1

wk

post

inte

rven

tion

None

rep

orte

d

Lite

racy

pro

mot

ing

inte

rven

tion,

hig

h

et a

l59

RCT

N =

205,

Uni

ted

Stat

es5–

11 m

o lo

w in

com

e,

mul

tieth

nic

fam

ilies

1In

crea

sed

rece

ptiv

e vo

cabu

lary

in

chi

ldre

n 13

–17

mo

of a

ge,

expr

essi

ve v

ocab

ular

y in

chi

ldre

n 18

–25

mo

of a

ge (

MCD

I-SF)

Incr

ease

d fr

eque

ncy

of r

eadi

ng a

t be

dtim

e (d

/wk)

at m

ean

age

of

18 m

o

RoR,

Silv

erst

ein

et a

l60Pr

e/po

st q

ualit

y im

prov

emen

tN

= 17

3, S

eatt

le, W

A5.

5 m

o–6

y4

Grea

ter

repo

rt o

f rea

ding

as

favo

rite

act

ivity

imm

edia

tely

aft

er

inte

rven

tion

Grea

ter

repo

rt o

f rea

ding

alo

ud a

s fa

vori

te a

ctiv

ity, >

10 c

hild

ren’

s bo

oks

in h

ome,

and

rea

ding

alo

ud

at le

ast o

nce

per

wk

imm

edia

tely

po

stin

terv

entio

nGr

eate

st e

ffect

for

non-

Engl

ish

spea

kers

RoR,

Nee

dlm

an e

t al6

Quas

i-exp

erim

enta

l hi

stor

ical

con

trol

sN

= 16

47, 1

0 st

ates

in

Unite

d St

ates

6–72

mo

4No

ne r

epor

ted

Grea

ter

repo

rt o

f rea

ding

alo

ud a

s fa

vori

te a

ctiv

ity, >

10 c

hild

ren’

s bo

oks

in h

ome,

and

rea

ding

alo

ud

at b

edtim

e, a

nd a

loud

≥3

per

wk

imm

edia

tely

pos

tinte

rven

tion

Grea

test

effe

ct fo

r pa

rent

s w

ith le

ss

than

a c

ompl

eted

hig

h sc

hool

ed

ucat

ion.

RoR,

Jon

es e

t al61

Quas

i-exp

erim

enta

l Pr

ospe

ctiv

e co

ntro

lled

stud

y

N =

352,

Lou

isvi

lle, K

Y2–

24 m

o2

None

rep

orte

dM

ore

likel

y to

rep

ort e

njoy

men

t in

shar

ed r

eadi

ng 2

y p

ostin

terv

entio

n


Three interventions in which the promotion of early literacy was evaluated had relatively consistent results. Three ROR studies revealed a significant increase in the number of parents reporting reading aloud as their favorite activity with their child or increased frequency of reading on a weekly basis in cross-sectional samples or quasi-experimental studies.6, 60, 61 These effects were stronger among non-English speaking families60 and families with less than a completed high school education.6 The ROR + M intervention resulted in greater mathematics engagement by parents as well.62 The Literacy Promoting Intervention by High et al59 was associated with increased receptive and expressive vocabulary.

DIsCussIOn

In the past 15 years, multiple new interventions have been developed and tested in connection with primary care settings with the goal of improving the developmental trajectories of young children. Twenty-four interventions are included in this review, with data from 48 studies, primarily evaluated by RCT or quasi-experimental study design. A number of these interventions were evaluated across multiple cities and countries in studies with >3000 participants.

The evolution of interventions to promote development of young children in primary care settings is evident when comparing our findings to those of the systematic review by Regalado and Halfon4 in 2001. As documented in the previous review, educational interventions were focused on positive parent-child interactions and improved parental knowledge about child development but did not change parenting behavior or child development outcomes.63 – 65 In contrast, 2 interventions explicitly designed to improve parental confidence and



2017



December 2017

140

Inte

rven

tion,

Ref

eren

ceSt

udy

Desi

gnSa

mpl

e Si

ze, L

ocat

ion,

Ag

eAg

e, S

peci

fic P

opul

atio

nLe

vels

of E

vide

nce

Effe

ct

Child

out

com

esPa

rent

out

com

esLo

w in

com

e fa

mili

es,

mos

tly A

fric

an

Amer

ican

R oR

+ M

, Jon

es e

t al62

Coho

rt s

tudy

N =

72, S

outh

ern

Unite

d St

ates

12–3

6 m

o3

None

rep

orte

dIn

crea

sed

read

ing

activ

ities

rel

ated

to

mat

h (c

ount

ing,

sha

pes,

num

bers

, ad

ditio

n/su

btra

ctio

n, a

nd p

ositi

on),

mat

hem

atic

s en

gage

men

t sco

re a

t 3

wk

post

inte

rven

tion

Low

inco

me

fam

ilies

, m

ostly

Afr

ican

Am

eric

an

BBP,

Bab

y Bu

sine

ss P

rogr

am; B

DI, B

eck

Depr

essi

on In

vent

ory;

MCD

I-SF,

Mac

Arth

ur C

omm

unic

atio

n an

d De

velo

pmen

t Inv

ento

ries

– S

hort

For

m; P

SI, P

aren

ting

Stre

ss In

dex;

ThB

, The

hap

pies

t Bab

y; V

AS, V

isua

l Ana

log

Scal

e.

TABL

e 6

Cont

inue

d


competence through skill building66 and coaching5 enhanced the quality of parent-child interactions in small trials (<50 participants).

The interventions summarized in this review continued this trajectory of incorporating new strategies to enhance parental skill building and parent-child interactions supported by behavior change theory.67, 68 These strategies included vicarious learning from peers, role play, homework, feedback through coaching, videotaped observation, and identification of parenting strengths. In some studies, the parental factors that could explain mechanisms of action were measured and included parental resilience, 31 satisfaction, 15, 35, 38 – 40, 45 self- efficacy, 15, 35, 38 – 40, 45, 46, 52 and stress.17, 18, 32, 38, 44, 45, 52 The authors of studies of behavioral interventions also frequently explored the impact on parental mental health as a potential mediating factor.42, 47 –51

The primary challenge in synthesizing and drawing firm conclusions about the efficacy or effectiveness of specific interventions, however, lies in the heterogeneity of outcome measures and reported findings. Among the general developmental studies, a different child outcome measure was used in almost every study, and 3 studies16, 32, 34 had no child outcome measures as part of the evaluation, making comparisons across these studies difficult. Even among studies of the same interventions, the results varied in terms of the time when evaluations occurred and the specific outcome measures that demonstrated improvement (eg, prevention of developmental delay versus behavior problems in VIP and HS studies).18, 23, 26, 28 The behavioral development studies were more consistent in their use of the CBCL or Eyberg Child Behavior Inventory (ECBI) as outcome measures of child behavioral problems.

Greater consensus on which child outcomes are most important from a clinical perspective and which validated tools are optimal for assessment of these outcomes is needed, particularly for general developmental interventions. Other specialties, such as mental health, face similar challenges69 and may serve as examples for future standardization of quality and outcome measures.70, 71 With respect to general developmental outcomes, measures of language development may be particularly important given the disparities that exist in this developmental domain72, 73 and the association with later academic achievement.74, 75 Studies with longer follow-up periods, such as studies of home visiting or preschool programs, 76, 77 may help identify measures in early childhood that predict long-term health and academic success. The behavioral development studies showed more consistent impact on the clinically relevant measures of behavioral intensity and behavior problems.

Although the factors related to the mechanism of action of interventions were assessed in many studies, the variability of results limits our ability to understand precisely why some interventions work over others, who benefits from interventions, and what may be the common pathway by which different interventions impact the same outcomes. This basic understanding is necessary to inform future policy and services.3 The collection of VIP studies provides an example research strategy to thoroughly study an intervention. The studies identified families that benefited most (on the basis of education level), 18 potential mechanism of action (mediators including responsive parenting and maternal depression), 20 and explored clinically significant outcomes such as language, harsh discipline, and social emotional development.21, 23

In addition to examining the individual mechanism of action of the interventions, researchers for future studies should attempt to identify key components that may be common across multiple interventions. Drawing again from the mental health literature, the examination of key components should include intervention content as well as factors that impact the process of intervention delivery (eg, participant and provider attitudes, specific types of interactions, and provider approach to influencing behavior change).78 Common elements of evidence-based psychologic treatments for adult anxiety and depression, for example, include altering cognitive appraisal, modifying emotion-driven behavior, preventing emotional avoidance, 79 as well as demonstrations of warmth and empathy, clear explanations, focused discussion on practical concerns, and well-organized sessions.78 Identification of common key components of developmental interventions could have implications for the feasibility of dissemination of these interventions into community settings where the majority of children receive primary care.

Several notable gaps in the literature limit the feasibility of replicating individual interventions in community settings. First, the cost of many of the identified interventions is not well described. VIP and HS reported relatively low costs compared with programs such as home visiting or Early Head Start, although both required a child development specialist.20, 26, 27 The descriptions of trainings are similarly limited. Most of the interventions were delivered by child development specialists or health care professionals that likely bring additional skills and knowledge to interactions with parents. Access to child development specialists is limited in rural settings; thus, understanding the specific skills



2017



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140


needed to conduct the intervention is critical. Chang et al33 provided an example of a detailed description of paraprofessionals training that could be used in resource-limited settings.

Implications

Although multiple studies showed positive change in a number of different child development and parental outcomes, the heterogeneity of results limit the clear distinction between effective and noneffective interventions. To identify the services and policies that will optimally promote the development of young children, we need a clear understanding of the end point we are collectively trying to achieve. We need greater consensus on the best measures of these outcomes, and we need to understand why interventions work and who benefits most. When considering implementation of these interventions in community settings, health professionals must consider the availability and expertise of their staff and the cost of training and implementation. Examples of highly targeted interventions delivered by paraprofessionals may provide some direction for future dissemination strategies.33, 34

Limitations

This review has several limitations. Only articles published in English were reviewed. In addition, the inclusion criteria requiring a connection to primary care limited the focus to US populations and countries with similar health systems. Initially, we considered

limiting our review to studies conducted in the United States given the significant differences between health care systems around the world. Ultimately, we sought to include international studies because multiple interventions were studied in the United States and internationally, and interventions designed for settings with varying levels of resource allocation may also be relevant to lower-resource or rural settings in the United States. Our review may have missed eligible studies for various reasons. Although our search terms were intentionally broad, other terms used to describe similar interventions may have resulted in missed studies. Additional studies may have been missed or excluded because of ambiguity with respect to the age of children enrolled or the connection to primary care. Interventions conducted without a connection to primary care were excluded even if other primary care–based studies of the same intervention were included. We also excluded studies targeting specific populations such as extremely premature infants and parents with diagnosed depression or substance abuse disorders because these populations frequently require targeted therapies or treatment with medication. Finally, the Levels of Evidence system used to summarize and compare the study designs across interventions is not a definitive indicator of the quality of the study because it does not assess bias related to blinding, instrument validation, or observer versus self-report measures. The decision to use this system was based on feasibility

given the variety of study designs used and the variability of reported factors that impact study quality.

COnCLusIOns

Several interventions delivered in primary care settings can positively impact developmental and behavioral trajectories of children aged 0 to 3 years. These interventions involve the child’s parents and frequently a team of health professionals. Common measures of child development outcomes are needed to compare efficacy across studies. Further exploration of why certain interventions work and who benefits from interventions could inform future policy to make these services more widely available.

ABBRevIATIOns

BB: Building BlocksCBCL: Child Behavior ChecklistCFD: Care for DevelopmentECBI: Eyberg Child Behavior

InventoryHS: Healthy StepsIY: Incredible YearsPCIT: Parent-Child Interaction

TherapyPOC: Play with Our ChildrenPP: PrePareRCT: randomized controlled trialROR: Reach Out and ReadROR + M: Reach Out and Read

plus MathematicsSDP: Sit Down and PlayTriple P: Positive Parenting

ProgramVIP: Video Interaction Project



2017



December 2017

140

Accepted for publication Sep 11, 2017

Address correspondence to Elizabeth Peacock-Chambers, MD, MSc, Department of Pediatrics, Baystate Medical Center, 3601 Main St, Springfield, MA 01199. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; online, 1098-4275).

Copyright © 2017 by the American Academy of Pediatrics

FInAnCIAL DIsCLOsuRe: The authors have indicated they have no financial relationships relevant to this article to disclose.

FunDInG: Supported by a health Resources and Services Administration T32 grant hP10028 (I09940000730) from June 2014 to June 2015.


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ReFeRenCes

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POTenTIAL COnFLICT OF InTeResT: The authors have indicated they have no potential conflicts of interest to disclose.

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